The present invention relates generally to the field of biocompatible prosthetic devices having good mechanical properties and good hemocompatibility. More particularly, it concerns biocompatible heart valves fabricated from a blend of a polyurethane (PU) and a polysiliconeurethane (PSU).
Continuing advances in prosthetic heart valve design and techniques for their implantation have improved the survival time and quality of life for patients who receive these devices. In an ongoing effort to develop more durable and compatible heart valve prostheses, researchers have used a variety of techniques to determine the suitability of given valve materials for a given implant application. This suitability is generally known as xe2x80x9cbiocompatibility.xe2x80x9d Researchers commonly deal with biocompatibility in terms of whether the implant material or its degradation products, if any, initiate adverse tissue responses in the host, or conversely, whether deleterious changes in the chemical, physical, or mechanical properties of the implant material are caused by the host environment. The term xe2x80x9chemocompatibilityxe2x80x9d refers more specifically to biocompatibility issues related to implantation of prosthetic devices (such as prosthetic heart valves and vascular or coronary stents) in the cardiovascular system, such as any toxicity of implant materials to red blood cells or tissues contacted by the implanted material, thrombosis, and induction of mineralization. The vast majority of biocompatibility studies to date have involved in vitro testing or animal models. However, the ultimate test for biocompatibility of a material, device, or prosthesis is human implantation.
To be clinically effective, a heart valve must endure a difficult environment, including cyclic bending stresses on the leaflets and high pressure transients across the valve, for long periods of time. Prosthetic heart valves currently in clinical use are of two general varieties: mechanical or tissue. Mechanical heart valves are very durable, but their use is complicated by higher risks of thromboembolism, hemorrhage, and hemolysis. Use of mechanical heart valves suffers the further complication of requiring chronic systemic anticoagulation of the patient. Tissue valves require no chronic anticoagulation, on the other hand, but often fail in a far shorter period of time than mechanical valves due to mineralization (the formation of mineral deposits, e.g. calcium phosphates) and tissue tearing.
Potential alternative materials that are sufficiently durable and blood compatible for use in a prosthetic heart valve include (i) non-glutaraldehyde fixed bovine pericardial tissue, which studies in an ovine mitral model have shown to be mineralized to a lesser extent than glutaraldehyde-fixed tissue and (ii) synthetic polymers, such as polyurethanes, which have been reported in many different models to also show less mineralization than glutaraldehyde-fixed bovine pericardial tissue.
Mineralization, however, remains an obstacle to the clinical development of a polymer-based heart valve. Artificial heart valve bladders and pacemaker leads fabricated of polyurethane have been observed to undergo mineralization in mammalian trials. The precise mechanism for pathological mineralization of cardiovascular tissue or heart valve prostheses is not well understood. Generally, the term xe2x80x9cpathologic mineralizationxe2x80x9d refers to deposition of minerals, typically calcium phosphate mineral salts, in association with a disease process. See Schoen et al., xe2x80x9cBiomaterial-assisted calcification: Pathology, mechanisms, and strategies for prevention,xe2x80x9d J. Biomed. Mater. Res.: Applied Biomaterials, Vol. 22 A1, 11-36 (1988), incorporated herein by reference.
Mineralization may be due to host factors, implant factors, or extraneous factors such as mechanical stress, or combinations of the foregoing. Some evidence suggests calcium deposits are related to devitalized cells, especially membrane cells, where the calcium pump (Ca+2-Mg+2-ATPase) responsible for maintaining low intracellular calcium levels is weakened or no longer functioning. Mineralization has been observed to begin with an accumulation of calcium and phosphorous (present as hydroxyapatite and other calcium phosphates), which develops into nodules that can eventually lead to a valve failure.
A permanent implantable prosthetic polymeric heart valve was first described at least four decades ago (Akutsu, T., Dreyer, B., Kolff, W. J., J. Appl. Physiol. 14:1045-1048 (1959)), yet reduction of the concept to clinical practice has eluded the medical device industry, due to leaflet stiffening, tearing, thrombosis, calcification, and valve stenosis not predicted by in vitro models. Reported physical properties of materials such as polyetherurethanes exceed the requirements of cardiac valves. Biomer, a polyetherurethane urea once thought to be the ideal blood contacting material for implantable devices such as heart valves, was later reported to be prone to mineralization in the juvenile sheep model (Hilbert, S. L. et al., J. Thorac. Cardiovasc. Surg. 94: 419-429 (1987)), and its use as a primary component of a clinical prosthetic heart valve has not materialized. While the observed mineralization was first attributed to microscopic defects in the leaflet surface, it was later appreciated that the polyether segment of the polyurethane has the capacity to associate with calcium ions in the blood, thereby leading to mineralization of the material itself (Thoma, R. J. et al., J. Biomat. Appl. 3:180-206 (1988)). Reports of mineralized polyurethane blood pump bladders supported the polyurethane mineralization theory (Coleman, D. L. Trans. Am. Soc. Artif. Intern. Organs 27: 708-713 (1981)). However, it was not appreciated that mineralized thrombus comprised the vast majority of the calcium present upon polymer valve leaflets, and therefore, for materials not inherently calcific, inhibition of leaflet thrombosis simultaneously prevents leaflet calcification.
The location of mineralization sites on a heart valve prosthesis may be intrinsic, i.e., within the boundaries of the biomaterials of the prosthesis, or extrinsic, i.e., outside the biomaterials, though possibly attached to the valve prosthesis, e.g., within thrombus or other adherent tissue. With polymer valves, it is generally believed that both intrinsic and extrinsic mineralization must be controlled. Therefore, a biocompatible heart valve prosthesis is needed that is resistant not only to thrombus formation, but also to mineralization, particularly extrinsic mineralization, i.e., mineralization of thrombus or tissue adherent to valve leaflets. At the same time, the heart valve prosthesis should possess good mechanical properties to allow it to function adequately for a relatively long time. Despite the demonstrated need, a polymer suitable for long-term implantation as a primary component of a heart valve has remained elusive.
Polyetherurethane (PEU) is typically synthesized from a diisocyanate (such as diphenylmethane-4,4xe2x80x2-diisocyanate (MDI)), a diol chain extender (such as 1,4-butanediol (BD)), and a polytetramethylene oxide with a molecular weight of about 2000 (PTMO-2000) (available under the trade name Terethane 2000 Polyether Glycol, Dupont, Wilmington, Del.) or other polyalkylene oxide as soft segment. Polyetherurethane urea (PEUU) is typically synthesized using MDI, PTMO, and ethylene diamine (ED) or other diamine chain extender. Both PEU and PEUU have the mechanical properties required to provide prosthesis durability in accelerated fatigue testing as described by Bemacca G M et al., xe2x80x9cPolyurethane heart valve durability: effects of leaflet thickness and material,xe2x80x9d Int. J. Artif Organs, 20, 327-331 (1997), incorporated herein by reference. However, other chain extenders, e.g., alkyl diols or diamines and other soft segments, e.g., polycarbonate having two isocyanate-reactive terminal groups such as poly(1,6-hexyl 1,2-ethyl carbonate) diol or polyalkylene oxide, such as polyhexamethylene oxide (PHMO), can also be used.
Polysiliconeurethane (PSU) (a.k.a., silicone-urethane copolymer) is typically synthesized using MDI, BD, and a polydiorganosiloxane having two isocyanate-reactive terminal groups, such as polydimethylsiloxane (PDMS) end capped with alkyl alcohol as soft segment. The high surface activity of PDMS results in its relatively higher surface concentration relative to its bulk concentration. Due to the better hemocompatibility of silicone rubber relative to polyetherurethane as described in Hanson S R et al., xe2x80x9cIn vivo evaluation of artificial surfaces with a nonhuman primate model of arterial thrombosis,xe2x80x9d J. Lab. Clin. Med., 95, 289-304 (1980), incorporated herein by reference, PSU also provides better hemocompatibility than either PEU or PEUU. However, PSU has thus far lacked the mechanical strength, fatigue resistance, and durability of either PEU or PEUU needed for a durable prosthetic heart valve.
Hybrid polymers containing both polyether and polydiorganosiloxane soft segments can also be made. Martin D K et al., xe2x80x9cPolydimethylsiloxane/polyether-mixed macrodiol-based polyurethane elastomers: biostability,xe2x80x9d Biomaterials, 21, 1021-1029 (2000), incorporated herein by reference, describe polyurethanes synthesized using MDI and BD as hard segment, and mixtures of polyhexamethylene oxide (PHMO) and polydimethylsiloxane (PDMS) macrodiols as soft segment. While the mechanical strength of the polymer increases with the fraction of PHMO used in the synthesis, the biodegradation resistance increases with the fraction of PDMS. The authors report that a PHMO:PDMS ratio of 1:4 provides the optimum polymer in terms of flexibility, strength, and biostability.
G M Bemacca et al., xe2x80x9cHydrodynamic function of polyurethane prosthetic heart valves: Influences of Young""s modulus and leaflet thickness,xe2x80x9d in Sixth World Biomaterials Congress Transactions, Society for Biomaterials, Minneapolis, Minn., 2000, p. 584, and Fisher and M Butterfield, xe2x80x9cA new design of polymer synthetic leaflet heart valve,xe2x80x9d in Sixth World Biomaterials Congress Transactions, Society for Biomaterials, Minneapolis, Minn., 2000, p. 68, report in vitro studies of tri-leaflet heart valves, wherein the leaflets of the different valves comprised different polysiliconeurethanes (commercially available under the trade name Elast-Eon(trademark), Elastomedic Pty Ltd., Chatswood, Australia).
Ward R S, xe2x80x9cSurface Modification Prior to Surface Formulation: Control of Polymer Surface Properties Via Bulk Composition,xe2x80x9d Medical Plastics and Biochemicals, 2, 34-41, 1995, describes XPS analysis of PEU modified with less than 5% w/w PDMS ends groups that finds the surface to be essentially PDMS. Furthermore, Ward R S et al., xe2x80x9cHigh-strength, optically clear, silicone-urethane thermoplastics for biomedical use: Bulk properties,xe2x80x9d in Sixth World Biomaterials Congress Transactions, Society for Biomaterials, Minneapolis, Minn., 2000, p. 431, describes PSU/PEU hybrid copolymers varying in ratio of polyether to polysilicone in the soft segment (from all polysilicone to  greater than 99%, w/w, polyether).
Without being bound by any particular theory, it is believed that the high surface activity of PDMS and similar silicone-based polymer segments can be exploited to achieve a polymeric heart valve with a surface concentration of PDMS far exceeding the bulk concentration of PDMS in a copolymer or a polymer mixture.
This invention relates to biocompatible heart valve prostheses comprising a blend of a polyurethane and a polysiliconeurethane. More particularly, this invention relates to biocompatible prostheses that are hemocompatible and resistant to in vivo mineralization and/or biological degradation.
In one embodiment, the invention is directed to a prosthetic heart valve comprising a stent defining a blood flow path and a plurality of leaflets, each leaflet comprising a blend of a polyurethane and a polysiliconeurethane.
In another embodiment, the invention relates to a method of reducing mineralization or thrombosis of an implanted prosthesis, comprising (i) prior to implantation, fabricating the prosthesis from a blend of a polyurethane and a polysiliconeurethane, and (ii) implanting the prosthesis.